When Ipswich Hospital trust saw a need for change in back pain care, a working party set about transforming the service, with outstanding results. John Skinner and colleagues explain
Ipswich Hospital trust serves a population of about 350,000 people, but its spinal surgical and pain clinic serves a larger population, with referrals from outside East Suffolk.
Our first triage service was set up 10 years ago, when services for spinal problems first became inundated with the volume of referrals. In 2003 we established a second-generation service which has anticipated the Department of Health's recent musculoskeletal services framework and successfully implemented its aims.
A working party was convened under the leadership of pain medicine consultant Dr John Skinner and spinal surgery consultant Dr David Sharp. Membership included stakeholders from the pain clinic and spinal surgery and physiotherapy departments as well as general practice, community physiotherapy and a primary care trust medical adviser.
After three years of discussions, funding was secured from the PCTs. This money allowed new appointments to be made to community physiotherapy teams. It also provided two extended scope physiotherapy posts, hospital spinal surgical and pain consultant sessions, administrative support, and clinical and office accommodation for the multidisciplinary team in the community.
Referral and clinical guidelines were written and circulated to GPs and community physiotherapists.
Changing old habits
All patients with spinal pain are referred by their GP to primary care physiotherapists. GPs can no longer refer patients to secondary care, except those presenting with 'red flags' for serious spinal pathology. Community physiotherapists aim to see all acute patients within two weeks of GP referral. After four weeks of treatment, if the patient has not progressed, a 'yellow flag' assessment of risk factors for chronicity will be carried out with support from the extended scope physiotherapist.
If necessary, the case will be discussed at a multidisciplinary team meeting with a spinal surgeon and pain consultant. A decision is made here on the further management of this patient. All this occurs in primary care, and it is not unless patients are seen in an Ipswich Hospital clinic that they become a secondary care patient.
Before the introduction of this new pathway, gains in patient care achieved by its predecessor had been lost because of the sheer volume of referrals. Waiting times for the spinal orthopaedic clinic initially reduced from 12 to three months, but had grown to seven months by February 2002.
For 20 per cent of these patients the outcome of their first attendance at the spinal clinic was simply referral to physiotherapy. Both clinics also had their own waiting lists for the minority of patients requiring surgery, nerve blocks or assistance with self help through our pain-management programme. The accumulated effect of serial waits often amounted to over 20 months.
Aspects of the service pathway were audited in 2004, 2005, and 2006. There was increasing uptake of the new system and in June 2004 the waiting time for those selected for specialist assessment by the extended scope physiotherapists and the multidisciplinary team meeting had fallen to 18 days.
In a nine-month period in 2005, 70 per cent of all patients referred by community physiotherapists for assessment by the extended scope physiotherapists were subsequently cared for entirely in primary care. The remainder, 30 per cent, were reviewed at the multidisciplinary team meeting.
An audit from May 2005 to February 2006 showed 4,617 spinal patients were treated by community physiotherapists. Of those, 646, or 14 per cent, were seen in joint extended scope physiotherapist/physiotherapist clinics and 305, or 6.6 per cent, were discussed at the multidisciplinary team meeting. Five per cent - 220 - were taken into secondary care.
The secondary care tariff is under discussion. At the time of the third audit, a secondary referral cost£300. Under the old system the PCT would have paid£128,000 for these inappropriate referrals to secondary care.
Fulfilling the framework
Although they had worked together for some time before the new system was launched in 2003, physiotherapists and consultants in spinal surgery and pain medicine now have a much better appreciation of each other's clinical skills and greater integration of their contributions to patient care.
The most evident benefit to patient care has been that the right patients are now being assessed quickly and referred to the appropriate professional whether in the community clinics or hospital. This should result in improved clinical outcomes.
Three examples illustrate this. First, early identification of those at most risk of developing chronic back pain - yellow flags. Suitable education in self-management along cognitive behavioural lines can now be delivered which should reduce long-term disability.
Second, the new pathway enables patients with sciatica due to lumbar disc prolapse, unremitting after a few months of conservative management, to progress through investigation and treatment with dorsal root ganglion blocks or surgical discectomy.
Third, the competency of physiotherapists in the community teams has been raised through regular contact with their extended scope specialist colleagues.
Traditional approaches to managing back pain have been transformed by use of a simple multidisciplinary team approach to managing all patients presenting to the GP with spinal symptoms.
This system is effective clinically and cuts costs. Our system predicts that proposals made by the musculoskeletal services framework will successfully help to resolve problems with the management of patients with spinal symptoms. -
Dr John Skinner and Dr David Bailey are consultants in pain medicine, and Dr David Sharp and Dr John Powell consultants in spinal surgery at Ipswich Hospital trust. Alison Garner and Gary Rogerson are extended scope physiotherapists at Suffolk PCT.